Madison Square Senior Living II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the CARE tool. LPA met with caregiver who then contacted Licensee who arrived to the facility shortly afterwards. Today's visit, LPA and Licensee conducted a tour of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: residents bedrooms, bathroom, laundry room, kitchen and the common areas. LPA observed facility to be clean and sanitary. LPA observed medications, sharps and toxins to be locked and secured. LPA observed fire extinguisher present with service date of October 2, 2025. At this time, Licensee reported no concerns at the facility. LPA was unable to complete today's inspection, LPA will return at a later date to complete the annual inspection. No deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 14, 2025

Type of visit: Case Management - Other

On May 14, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding unpaid late licensing fees. LPA met with staff and explained the purpose of the visit. Today's visit, LPA explained that there was a $495 annual licensing fee that was billed on October 2, 2024 with due date of facility anniversary date December 29, 2024, which has remained unpaid. A $247 late fee has since been assessed with an overall remaining balance of $742. Payment can be made online at https://www.cdss.ca.gov/inforesources/community-care/licensing-fees If Licensee wish to pay by check and/or money order please make check or money order payable to: CA Department of Social Services MS 9-3-67 P.O. Box 944243 Sacramento, CA 94244-2430 As a result of the visit, deficiencies cited. Exit interview and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, May 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.185(e) · Plan of correction due date: May 23, 2025

§1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement is not met as evidenced by: Based on file review, Licensee did not comply to the section cited above as Licensee has an outstanding fee balance of $742 whihc poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: Licensee is to submit proof of annual licensing fee payment to LPA Yang by fax and/or email. POC is due Friday May 23, 2025.

Type of visit: Case Management - Legal/Non-compliance

On 12/19/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a quarterly case management visit as agreed during Non-Compliance Conference held on November 26, 2024. LPA met with Administrator and explained the purpose of the visit. During today's visit, LPA conducted a file audit to ensure files are complete. LPA observed presence of home health and hospice correspondence between agency and facility for R1, R2 and R3. LPA conducted a file review for personnel and resident records. LPA observed the required documents present and completed for residents in care. No deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 19, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced on 12/17/2024 to conduct a required annual inspection utilizing the inspection tool. LPA met with Administrator and explained the purpose of the visit. During today's inspection, LPA and Caregiver conducted an inspection of the facility. Areas toured included but not limited to: four resident bedrooms, two bathrooms, laundry room, kitchen and the common areas. LPA observed facility to have two days of perishable and seven days of non perishable food. LPA observed knives, toxins and medications to be locked and secured. LPA observed laundry room to be locked and inaccessible to residents in care. Fire extinguisher observed to be updated with State Fire Marshal seal tag dated October 8, 2024. It was discussed that Administrator is to audit medications as needed to ensure medications are given as prescribed and for Medication Administration Records are documented correctly . LPA observed presence of home health and hospice correspondence between agency and facility for R1, R2 and R3. LPA conducted a file review for personnel and resident records. LPA observed the required documents present and completed for residents in care. At this time, LIC 500 and liability insurance is to be emailed to LPA by Friday December 27, 2024. No deficiencies cited. Exit interview and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2024

Type of visit: Office

On 11/26/2024 at 10:00 AM, a Non-Compliance Conference was held at the Sacramento North Regional Office located at 9835 Goethe Road Suite 100, Sacramento CA 95827. Present were: Regional Manager, Alycia Rayner, Licensing Program Manager, Maribeth Senty, Licensing Program Analyst, Kevin Mknelly Licensing Program Analyst Cassie Yang, and Administrator, Darius Stir (representing licensee Madison Square Senior Living LLC). A non-compliance plan was developed with the licensee on today's date as it relates recent compliance history. The licensee was in agreement with the drafted non-compliance plan. No new citations are issued as a result of today's meeting. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 25, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassie Yang arrived to the facility to conduct a case management visit regarding three incident reports the Department received. LPA met with Caregiver and explained the purpose of the visit. Administrator then arrived to the facility shortly afterwards. The first incident report was regarding R1 who left the facility unsupervised at approximately 5:30AM and was found an hour later by local law enforcement. The date of occurrence was 06-15-2024, which the Department was not notified until 10-01-2024. Note that facility was cited on 12-14-2023 and 9-19-2024 for failing to met reporting requirements. The second incident report occurred on 09-21-2024 regarding R1 again who left the facility unsupervised at approximately 2:20pm and was found by local law enforcement at approximately 3:40pm. Base on file review of R1's LIC 602A Physician's Report for Residential Care Facilities for the Elderly, it revealed R1 cannot leave the facility unassisted. The third incident report occurred on 09-25-2024 regarding R2 was transported to the emergency room as R2 was out of three medications, which R2 returned to the facility with new prescriptions orders. Based on interview conducted with Administrator revealed the empty bottles were placed to the side as a reminder for refills but was left forgotten. File review of R2's Centrally Stored Medication and Destruction Record revealed Gabapentin was refilled 7-22-2024, a month worth supply, and then the next refill was on 9-26-2024. LPA observed medication for 8-22-2024 to 9-25-2024 to be missing. As a result, please see LIC 809-D for the deficiencies observed today. Additionally, $250 civil penalty assessed as reporting requirement violation was recently cited within a 12 month period. Exit interview and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 9, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on file review, Licensee did not comply as LPA did not receive an incident report for R3 on an incident occuring on 9-16-2024 and receiving an incident report for R1 which occurred approximately three months prior to reporting to CCLD which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: Same violation POC is pending which is due on 10-9-2024. Once received, LPA will clear both POC's. Additionally, LPA will update Licensee if and when office meeting will be scheduled between the Department and Licensee.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 8, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on file review and interview, Licensee did not comply to the section above as it was observed that R2 was out of three medication refills for approximately a month prior to being sent out to the hospital for new refill orders which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: Licensee will submit a plan of facility procedure for R2's monthly medication to ensure refills are received in a timely manner. POC is due to LPA on 10-8-2024. Additionally, LPA will update Licensee if and when office meeting will be scheduled between the Department and Licensee.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Oct 8, 2024

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on file review, Licensee did not comply with the section cited above as R1 was reported to AWOL twice within this year which LIC602 stated R1 cannot leave facility unassisted, which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: - R1 and Conservator consented to Apple AirTag on R1. - Licensee will update R1's LIC 602 with PCP and reassess R1's needs and service plan to ensure R1 gets the care and supervision needed. -Provide LPA of appointment date by POC due date Additionally, LPA will update Licensee if and when office meeting will be scheduled between the Department and Licensee.

Type of visit: POC

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction visit regarding the deficiencies cited on 9-19-2024. LPA met with Administrator and explained the purpose of the visit. Plan of Corrections was originally due Friday 10-3-2024 but has been extended to Wednesday 10-9-2024: 22 CCR 87411 Personnel Requirements - Licensee is to conduct an audit of facility roster and associate any additional staff needed to roster. Licensee is to inform LPA Yang of completion. 22 CCR 87211 Reporting Requirements - Licensee is to submit a statement of understanding of the reporting requirements of 22 CCR Section 87211. LPA and Administrator discussed POC cannot be extended any further. Failure to correct will result to $100 per day civil penalty until POC received. Exit interview and a copy of report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2024

Allegation investigated: Facility failed to meet reporting requirements.

On 9/19/2024, Licensing Program Analysts (LPAs) Yang and Mikkelson arrived unannounced at the facility to open and deliver the findings of the allegation cited above. LPAs met with caregiver, who then contacted Administrator who then arrived to the facility shortly afterwards. Today's investigation, LPAs interviewed Administrator and condcuted file reviews. Result of investigation is as follow, please continue on LIC 9099-C. Substantiated LIC 9099-C... Allegation: Facility failed to meet reporting requirements. The Department investigated the following allegation. Based on interview conducted with Administrator on 9/19/2024, interview revealed that there has been a few recent falls. R1 had a fall a day prior to LPAs' visit who then was sent out to the emergency room for evaluation. Interview revealed that R1's family member was notified but LIC 624 UNUSUAL INCIDENT/INJURY REPORT has not been submitted to Licensing yet. Interview with Administrator further revealed that R2 had a fall on 08/24/2024, where R2 had a nose bleed. Administrator contacted R2's responsible party and was asked to not send R2 out for evaluation. Administrator stated LIC 624 UNUSUAL INCIDENT/INJURY REPORT was not submitted to Licensing regrading this incident. Based on Title 22 Section 87211, facility is required to provide written report to Licensing Division within seven days of occurrence. Based on the allegation, facility failed to meet reporting requirements, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. $250 repeated violation civil penalty assessed as facility was cited on 12/14/2023 for the same deficiency. Exit interview conducted and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 59-AS-20240916115315

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 4, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on file review and interview, Licensee did not comply to the section cited above as Licensee stated LIC 624 was not submitted for R2 for an incident that occurred on 08/24/2024, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee is to submit a statement of understanding of the reporting requirements of 22 CCR Section 87211. POC is due 10/4/2024, failure to provide POC by POC due date may result to $100 civil penalty per day until received/corrected.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Yang and Mikkelson arrived unannounced at the facility to conduct a case management visit regarding a deficiency LPAs observed. LPAs met with caregiver who then contacted Administrator who then arrived to the facility shortly afterwards. During LPAs visit, LPAs observed S1 to be working alone with residents in care. LPAs were informed S1 has been working at the facility since April 30, 2024. Based on file review, LPAs did not observe S1 to be associated to facility roster on Guardian. LPAs completed LIC 9182 with Administrator's signature to transfer S1's association to the facility. LPAs and Administrator discussed fire clearance as Room 1 and Room 3 are approved for ambulatory only. LPAs reminded Administrator that residents with non-ambulatory status due to physical and/or mental condition cannot reside in Room 1 and Room 3 until cleared by Sacramento Metro Fire Department. Additionally, LPAs reminded facility that based on State Marshal laws and regulation, fire door are to remain closed at all times. Deficiencies cited and civil penalty assessed. Please see LIC 809-D. Exit interview conducted and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(g)(2) · Plan of correction due date: Oct 4, 2024

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the section as LPAs observed S1 to be working at the facility without a criminal clearance transfer associated to the facility, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee completed LIC 9182 for S1. Licensee is to conduct an audit of facility roster and associate any additional staff needed to roster. Licensee is to inform LPA Yang by 10/4/2024 of completion. Failure to correct by POC due date may result to $100 civil penalty per day until received/corrected.

Type of visit: POC

On 2/15/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Proof of Correction (POC) visit. LPA met with caregiver, Princess Allen, who notified Supervisor, Samantha Shaw Camacho, who arrived to the facility shortly afterwards. Today's visit, LPA conducted a file review of two personnel and two staff files. Additionally, LPA conducted an inspection of the kitchen area to ensure there is a secured storage space for sharps. LPA cleared the following deficiencies: - 87211 Reporting Requirements - §1569.605 Liability insurance - 87412 Personnel Records - 87506 Resident Records - §1569.17 Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances - 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling - 87309 Storage Space - 87202 Fire Clearance LPA informed Supervisor a copy of POC clearance will be mailed to facility. LPA and Supervisor discussed Licensee submitting LIC 200 and facility sketch to request fire clearance of six non-ambulatory residents. No deficiencies cited. Exit interview conducted and a copy of the report will be emailed.the state’s words, verbatim · CDSS document, Feb 15, 2024

Type of visit: Case Management - Deficiencies

On 12/14/2023, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator, Darius Stir, and explained the purpose of the visit. During LPA's visit on 12/06/2023, it was discussed to submit LIC 624 regarding R1's hospitalization as LPA observed R1 being transported by Metro Fire. LPA has not receive the requested document. Additionally, on 12/06/2023, LPA requested a copy of liability insurance from Administrator. LPA then was informed day prior to today's visit that facility does not have an active liability insurance. Administrator stated license was not received. LPA observed a copy of license was provided on 12/28/2022 by Adult and Senior Program Centralized Application Bureau. During today's visit, LPA provided a physical copy to Administrator. Technical Support was offered and declined by Administrator. Deficiencies cited. Please see LIC 809-D. Exit interview and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 14, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Dec 3, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interview, Licensee did not comply with the section cited above as Licensee did not submit an incident report for R1 to Licensing as discussed on 12/6/2023, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: -Licensee will submit the requested LIC 624 for R1 to LPA Yang. -Additionally, Licensee will review CCR 87211 Reporting Requirement and notify LPA once completed. - POC is due by Friday, December 22, 2023.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.605 · Plan of correction due date: Jan 5, 2024

§1569.605 Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Based on interview, Licensee did not comply with the section cited above as Administrator informed LPA via email that facility does not have liability insurance, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Licensee was provided a physcial copy of license. Licensee will submit proof of facility liability insurance to LPA Yang by January 5, 2024.

Type of visit: POC

On 12/14/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction (POC) visit for deficiencies issued on 12/06/2023. LPA met with Administrator, Darius Stir, and explained the purpose of the visit. During visit of 12/06/2023, LPA cited the facility four (4) type A deficiencies. LPA explained all type A violations have POC due date within 24 hours, on 12/07/2023. - 87309 Storage Space - 87202 Fire Clearance - §1569.17 Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances - §1569.618 Administration and management of residential care facilities LPA received an email from Administrator at 12AM on 12/08/2023, with the requested POC's. Today's visit, civil penalties are assessed for failure to correct of $100 per day. Exit interview and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 14, 2023

Type of visit: Case Management - Other

On 12/14/2023, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator, Darius Stir, and explained the purpose of the visit. During LPA's last visit on 12/06/2023, civil penalty was cited for criminal clearance. LPA realized civil penalty was generated under wrong Health and Safety Code (HSC) violation of §1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling. Today's visit, LPA assessed civil penalty under §1569.17 Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances. Appeal rights was provided, and the 15 day for civil penalty appeal will restart as of today. Exit Interview conducted, and a copy of report and appeal rights was provided.the state’s words, verbatim · CDSS document, Dec 14, 2023

Type of visit: Required - 1 Year

On 12/6/2023 at approximately 1PM, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a Required 1-year annual inspection utilizing the CARE inspection tool. At time of arrival, LPA observed the presence of Metro Fire arrival. LPA met with Caregiver and Administrator at the door, and explained the purpose of the visit. Today's census is four with one resident on hospice services. Time of visit, LPA observed R1 to be transported to hospital for evaluation. LPA reminded Administrator to submit LIC 624 regarding R1's hospital transportation. LPA and Administrator conducted a tour of the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, (4) resident bedrooms, (2) bathroom, kitchen, laundry room and staff office/room. In the areas toured the following issued were observed: LPA observed the CCLD compliance poster (PUB 475) to be missing. LPA observed fire door to be opened using a door stopper. LPA observed fire extinguisher to be in need of service as last inspection was 10/17/2022. LPA observed sharps to be stored in an unsecured drawer. LPA observed R2 and R3 to be non-ambulatory based on file review and observed R2 and R3 to be residing in an ambulatory only room. LPA conducted a resident file review. LPA observed 4 of 4 files are incomplete for various required forms. Administrator stated he is in the process of completing all documents based on LIC 311F checklist. LPA conducted a personnel file review. LPA observed 1 of 2 files are incomplete for forms and training. LPA observed S2 to not have a personnel file. LPA observed no proof of CPR and First Aid training present on file. LPA observed S1 to be working at the facility which she "arrived five days ago" without any fingerprint clearance. LPA informed Administrator staff cannot work at the facility until the individual is fingerprinted and cleared. Please continue on LIC 809-C... LIC 809-C... LPA provided LIC 9182 to Administrator for clearance transfer as LPA observed facility to have only S2 associated to the facility. LPA provided LIC 311F to Administrator for file completion. LPA is requesting liability insurance to be provided to LPA Yang via email by Friday December 8, 2023. LPA and Administrator discussed submitting a new LIC 200 and facility sketch to LPA for a new fire inspection for 5 non-ambulatory and 1 ambulatory. As a result of this inspection, the following deficiencies were cited on LIC 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted with Administrator. Signature confirming documents were received was conducted with Caregiver who entered the facility shortly before exit interview. LPA received physical copy of LIC 9182 for S3. Report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 6, 2023

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual inspection. LPA met with Administrator Darius Stir and explained the purpose of the visit. LPA is conducting an annual inspection today but this report is being generated to clear the Post-Licensing inspection in the system. There are no citations issued on this report. Exit interview. Copy of report provided..the state’s words, verbatim · CDSS document, Dec 6, 2023